ASRA Guidelines for Holding Aspirin for Pain Procedures
According to the most recent evidence, aspirin should be continued during pain procedures unless there is a high risk of bleeding or the procedure involves a closed space such as intracranial surgery. 1
Risk Stratification for Pain Procedures
Low-Risk Procedures
- For most pain procedures, aspirin can be safely continued
- Dental procedures do not require interruption of aspirin therapy 1
- Cardiovascular, vascular, and orthopedic procedures generally do not require aspirin discontinuation 2
High-Risk Procedures
- Neurosurgical procedures or closed-space surgeries require aspirin discontinuation 5-10 days prior 2
- Spinal cord stimulator placement carries increased risk of epidural hematoma with aspirin 3, 4
- For patients with coagulation disorders, aspirin should be withdrawn prior to procedures 2
Special Considerations for Patients with Cardiovascular Disease
Patients with Coronary Stents
- For patients with coronary stents, aspirin should be continued throughout the perioperative period for non-closed space procedures 1
- If the procedure is within the time frame requiring dual antiplatelet therapy, particularly with drug-eluting stents (DES), consideration should be given to continuing both antiplatelet agents 5
Patients with Other Cardiovascular Disease
- For patients with established cardiovascular disease but without coronary stents, aspirin should likely be continued unless undergoing closed-space surgery 1
- For heart patients in particular, continued use of aspirin is recommended 2
Timing of Aspirin Discontinuation When Necessary
- If aspirin must be discontinued, it should be stopped 5-10 days before high-risk procedures 2
- This timeframe accounts for the irreversible inactivation of cyclooxygenase in platelets, which lasts for the entire lifespan of platelets (7-10 days) 2
Risk of Epidural Hematoma
- Spinal epidural hematoma is a rare but potentially devastating complication of neuraxial procedures 3
- Case reports have documented epidural hematoma formation after spinal cord stimulator placement in patients taking aspirin 3, 4
- The American Society of Regional Anesthesia and Pain Medicine (ASRA) recommends weighing risks and benefits of aspirin use in each patient undergoing high-risk procedures like spinal cord stimulator trials 4
Important Caveats and Pitfalls
- Failure to identify aspirin use before neuraxial procedures can lead to serious complications 4
- Multiple comorbidities that affect platelet function can compound the bleeding risk of aspirin 4
- For patients taking aspirin for primary prevention (without established cardiovascular disease), discontinuation during the perioperative period is likely appropriate, especially when there is a high risk of bleeding 1
- Patients with drug-eluting stents are at particularly high risk for stent thrombosis if antiplatelet therapy is discontinued prematurely 5
When making decisions about perioperative aspirin management, a careful assessment of both bleeding risk and thrombotic risk is essential, with particular attention to the type of pain procedure being performed and the patient's cardiovascular history.